Low-dose trifluoperazine may help ease Morgellons symptoms

Morgellons is a rare disorder characterized by delusions of skin infiltration by microbes or inanimate materials. Symptoms generally include a sense of intense itching and crawling under the skin, skin rashes and abrasions from scratching, and fatigue.

“We have found that a combination of empathetic counseling, treatment of skin lesions, and low-doses of trifluoperazine is safe, effective, and cost-effective for patients suffering from Morgellons disease,” coauthor Bernice Yan of Weill Cornell Medical College in New York City told Reuters Health in an email.

The team reviewed medical records of patients at Cornell who had at least two visits to the dermatology department from 2006 through August 2016.

Twenty-four patients (mean age, 57; 75% women) were included in the study and followed for a mean of 11.2 months. All patients received counseling and trifluoperazine initiated at 1 mg/day at bedtime, with uptitration of 1 mg/day every month, depending on signs and symptoms. Patients were assessed for extrapyramidal findings and mood changes during follow-up.

As reported online January 10 in JAMA Dermatology, seven patients (29%) returned to baseline function and 15 (63%) achieved at least 50% improvement.

Average trifluoperazine doses were 1.9 mg/day for 50% to 90% improvement and 2.3 mg/day for at least 90% improvement.

Mean times to disease control were 2.4 months for at least 50% disease control and 6.6 months for 90%. Patients who achieved baseline function had median doses of 2 mg/day and remained in remission at their last visit, with a mean remission time of 10 months.

When comparing patients receiving median dosages of 1 mg/day versus 2 mg/day, the median time to partial remission for both groups was 2.1 months, with a median duration of response of 2.3 months for 1 mg and 4.7 months for 2 mg.

Fifty percent of patients with median dosages of 1 mg/day and 71% of those with median doses of 2 mg/day achieved at least partial responses. Among those taking 2 mg/day, half achieved baseline function, with a median remission duration of 9.9 months.

Four patients (17%) reported minor adverse effects, including drowsiness in 2 patients, which resolved with time.

Yan said, “Psychiatrists should be aware of these findings, as historically, they have had strong expertise in prescribing and managing trifluoperazine for other diseases, and patients with Morgellons can benefit from their care.”

“I think awareness can be raised by continuing to provide quality, patient-centered care through collaborative and interdisciplinary medical teams,” she noted.

“Once providers appreciate the full range of options available to manage this complex disease,” she added, “they might feel more empowered to counsel patients and to make the necessary referrals.”

Dr. Donald Goff, Vice Chair for Research, Department of Psychiatry at NYU Langone Health in New York City, commented, “The authors have published the largest case series (on Morgellon’s disease) to date and have demonstrated that very low doses of the first-generation antipsychotic, trifluoperazine, are effective in many patients and well-tolerated.”

“While this is a useful contribution to the literature,” he said in an email to Reuters Health, “it does not represent a novel treatment approach - merely a relatively large series of case reports that describe outcomes.”

“The field needs a randomized controlled trial, ideally including a newer antipsychotic and placebo group, and including fixed does so that conclusions can be drawn about the relative effectiveness and tolerability of different drugs and different doses,” he said.

“At higher doses,” he noted, “trifluoperazine produces more neurologic side effects than the newer antipsychotics.”

“The authors did not observe any cases of tardive dyskinesia, a potentially irreversible movement disorder that can result from the older antipsychotics at a rate of approximately 3% to 5% per year," he said. “But it is a risk with trifluoperazine (and) should not be overlooked as a potential risk of treatment.”

“First-generation agents are more likely to cause tardive dyskinesia than second-generation agents, and use of a low dose does not necessarily reduce risk,” he added.

“Consideration should be given to better-tolerated newer agents, such as aripiprazole, which has fewer neurologic side effects and less risk of tardive dyskinesia,” Dr. Goff continued.

“Morgellon’s disease can cause great suffering - both from distress related to the belief that one is infested with parasites and from attempts by patients to rid themselves of the infestation,” he said.

“A relatively low risk of tardive dyskinesia may be acceptable with a treatment that offers substantial relief in most patients,” he concluded, “but the risk should be acknowledged.”

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